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Frequency of skin lesions in haemodialysis patients in four Iranian Hospitals.

Introduction

Chronic renal failure (CRF) is defined as irreversible dysfunction of the kidney and makes the patient dependent on dialysis or kidney transplantation [1]. Metabolic and endocrine functions normally performed by the kidney will be impaired and this may result in anaemia, malnutrition, problems in the metabolism of carbohydrates, fat and protein, incomplete consumption of energy, and metabolic bone diseases. Raised plasma levels of many polypeptide hormones including parathormone (PTH) are considered uraemic poisons [1]. Dermatological symptoms of kidney failure are only detected in advanced cases of the disease and therefore are not valuable in diagnosis of kidney failure [2]. Complete and precise examination of the skin, hair, nails, and mucosal membranes may reflect many of the following symptoms [1]. The skin colour may be pale due to anaemia or pale yellow due to the precipitation of chromium. Skin hyper-pigmentation may be due to an increase of melanocyte-stimulating hormone (MSH) in sun-exposed areas that results in melanin precipitation in basal and superficial epidermal layers. Extended ecchymosis is due to the problems in platelet aggregation and other haemostatic dysfunctions. Weak skin turgor is due to the CRF dehydration [1]. Generalised severe itching is seen in about one-third of cases with CRF [2]. Calcified panniculitis, perforating skin disorders, bullous dermatoses and nail problems are also detected in CRF.

We designed a study to evaluate skin problems in haemodialysis patients in four centres in Tehran.

Materials and methods

This study was performed by the Dermatology, Urology and Nephrology Research Centres in four dialysis centres in Tehran in 2006. The centres included Shaheed Hasheminejad (in affiliation with Iran University of Medical Sciences), Shaheed Labbafinejad, Shohada-e-Tajrish, and Loghman-e-Hakim hospitals (in affiliation with Shaheed Behesthi University of Medical Sciences). Skin diseases that were studied and evaluated are detailed in Table 1 but also included the following: perforating disorders; calciphylaxis; porphyria and pseudoporphyria; onychomycosis; clubbing; horizontal nail ridging; Terry's nail; hypersensitivity rashes; and malignant skin lesions. The dialysis patients were evaluated in three work shifts of morning, afternoon, and evening. In total, 215 patients with at least 1 year of dialysis were enrolled in the study. The findings were evaluated using chi-squared, Fisher's exact test and ANOVA tests. A P-value of less than 0.05 was considered statistically significant.

Results

A total of 215 patients (122 men and 93 women) with a mean age of 56.4 [+ or -] 16.2 years (range 17-86 years) was evaluated. Mean time on dialysis was 5.9 [+ or -] 5.5 years (range 1-27 years). Of the patients, 202 (94%) had at least one type of dermatological disease (Table 1), with the most prevalent diseases being xerosis (127 patients, 59.1%), pruritus (localised and generalised; 104 patients, 48.3%), and yellow discoloration (93 patients, 43.3%). Longitudinal ridging (25.6%), splinter haemorrhage (19.1%), and lack of lunulae (14%) were the most common problems in the nails. (The prevalence of splinter haemorrhage is about 10% in the general population [3].)

Mean age of the patients correlated significantly with the presence or absence of solar elastosis (70.1 [+ or -] 5.8 v 55.2 [+ or -] 16.2 years; P=0.01) and splinter haemorrhage (61.8 [+ or -] 13 v 52.2 [+ or -] 16.7 years; P=0.018). Mean age of the patients also correlated significantly with the presence or absence of longitudinal ridging (61.3 [+ or -] 12.5 and 58.4 [+ or -] 17.0 years; P=0.01).

The duration of dialysis and presence of dermatological diseases were also significantly correlated. Mean length of time that patients had received dialysis was compared with the presence or absence of discoloration (6.8 [+ or -] 5.5 v 5.3 [+ or -] 5.4 years; P=0.047), xerosis (6.6 [+ or -] 5.7 v 4.9 [+ or -] 5 years; P=0.019) and koilonychia (9.7 [+ or -] 5.8 v 5.5 [+ or -] 5.3 years; P=0.01).

Of the patients, 89 were housewives, 24 had indoor jobs, 18 had outdoor jobs, 66 were unemployed or retired, and 18 had no classified jobs. The relationship between the patients' jobs and solar elastosis and folliculitis was found to be statistically significant (P=0.055 and P=0.01, respectively; Table 2).

The presence of hepatitis C (HCV) antibodies and dermatological disorders was compared. In total, 10 patients had antibodies to HCV but there was no significant relationship with any dermatological disorder. One of 13 patients without a dermatological disorder and 9 of 202 patients with at least one skin disease had a positive anti-HCV antibody test; again there was no statistically significant relationship.

There were a number of underlying disorders that had resulted in CRF: diabetes mellitus (n=38); hypertension (n=62); glomerulonephritis (n=12); cystic kidney (n=14); diabetes mellitus and hypertension (n=10); analgesic nephropathy (n=7); neurogenic bladder (n=2); congenital narrowing of the ureter (n=2); kidney tuberculosis (n=1); and Alport syndrome (n=2). The cause of CRF in other patients was unknown. The relationship between the underlying disease and dermatological manifestations is shown in Table 3. A significant relationship was found between folliculitis and furunculosis with the underlying disorder (P=0.039 in both). Of 215 patients, 27 were smokers. Fisher's exact test showed no significant relationship between smoking and dermatological disorders.

No cases of the following dermatological disorders were detected in our study: perforating disorders; calcinosis cutis; calciphylaxis; porphyria; pseudoporphyria; palmar or plantar keratotic pits; Terry's nails; onychomycosis; transverse ridging; and clubbing.

Discussion

Chronic renal failure patients on haemodialysis experience many dermatological signs and symptoms during the treatment. Since these symptoms are rarely seen in the primary stages of the diseases, they are not sensitive enough for diagnosis of CRF. Pico et al. [4] evaluated 102 CRF patients on haemodialysis and showed that they all had at least one dermatological disease. The most common disease was skin pigmentation. Other symptoms included half-and-half nail, pruritus, and keratotic pits in palmar and plantar areas. Masmoudi et al. [5] studied 363 haemodialysis patients, of whom 88% had skin diseases with the most prevalent disease being xerosis (64%). Saray and associates found that the most prevalent skin disease in their patients was lack of lunulae in 127 (31.9%) followed by onychomycosis (19.2%) and splinter haemorrhage (13.7%) [6].

Pruritus has been reported in a number of studies. Stahle-Backdahl found that in 20 haemodialysis patients, severe and moderate pruritus were reported in 8% and 68% [7], while Subach showed that of 70 patients, 70% had pruritus during haemodialysis sessions [8]. In an evaluation of 130 patients receiving maintenance haemodialysis, Szepietowski and colleagues saw uraemic pruritus in 40.8%, and generalised pruritus in 14%. The severity of pruritus and concomitant sleep disorders were significantly correlated with duration of dialysis (P<0.05) but not with the patients' age and the underlying kidney disease [9].

In a study of 70 haemodialysis patients by Dyachenko and colleagues, 74.3% had pruritus that was generalised in 65.7% of the cases [10]. In another study on 100 haemodialysis patients, 82% had dermatological signs and symptoms. The most common disorders were xerosis (79%), pallor (60%) and pruritus (53%) [11].

We found a statistically significant relationship between the mean age of the patients and solar elastosis, splinter haemorrhage and longitudinal ridging. Such relationships have not been reported previously.

Another factor that was evaluated was the relationship between the duration of dialysis and dermatological symptoms. We found a statistically significant relationship between dialysis duration and yellow discoloration of the skin, xerosis and koilonychia. This is at variance with some previous studies that have found no relationship between dialysis duration and dermatological manifestations [6,10]. However, Tercedor and colleagues did show a significant relationship between the duration of dialysis and half-and-half nail (P=0.010) [12].

We also found a statistically significant relationship between the patients' job and solar elastosis and folliculitis; this has not been reported previously. In our study, the relationship between the underlying disorders that led to CRF and folliculitis and furunculosis was statistically significant. Again, this has not been previously reported.

Choi et al. showed hyperpigmentation in CRF patients receiving haemodialysis and who were also anti-HCV antibody positive [13]. However, in our study, we found no significant relationship between the presence of HCV-antibodies and dermatological symptoms.

In a study of 114 chronic haemodialysis patients, 2.6% had carcinomatous skin lesions [12]. However, in the present study, we saw only one case of basal cell carcinoma and the patient was treated with radiotherapy.

References

[1.] Sweeney S, Cropley T. Cutaneous changes in renal disorders. In: Fitzpatrick's Dermatology in General Medicine (Freedberg IM, Eisen AZ, Wolff K et al., eds), 6th edn, McGraw-Hill, New York, 2003, pp1041-1045.

[2.] Dyachenko P, Shustak A, Rozenman D. Hemodialysis-related pruritus and associated cutaneous manifestations. Int J Dermatol, 2006, 45, 664-667.

[3.] Kilpatrick ZM, Greenberg PA, Sanford JP. Splinter hemorrhages: their clinical significance. Arch Intern Med, 1965, 115, 730-735.

[4.] Pico MR, Lugo-Somolinos A, Sanchez JL et al. Cutaneous alterations in patients with chronic renal failure. Int J Dermatol, 1992, 31, 860-863.

[5.] Masmoudi A, Ben Hmida M, Mseddi M et al. Cutaneous manifestations of chronic hemodialysis. Prospective study of 363 cases. Press Med, 2006, 35, 399-406.

[6.] Saray Y, Seckin D, Gulec AT et al. Nail disorders in hemodialysis patients and renal transplant recipients: a case-control study. J Am Acad Dermatol, 2004, 50, 197-202.

[7.] Stahle-Backdahl M, Hagermark O, Lins LE. Pruritus in patients on maintenance hemodialysis. Acta Med Scand, 1988, 224, 55-60.

[8.] Subach RA, Marx MA. Evaluation of uremic pruritus at an outpatient hemodialysis unit. Ren Fail, 2002, 24, 609-614.

[9.] Szepietowski JC, Sikora M, Kusztal M et al. Uremic pruritus: a clinical study of maintenance hemodialysis patients. J Dermatol, 2002, 29, 621-627.

[10.] Dyachenko P, Shustak A, Rozenman D. Hemodialysis-related pruritus and associated cutaneous manifestations. Int J Dermatol, 2006, 45, 664-667.

[11.] Udayakumar P, Balasubramanian S, Ramalingam KS et al. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. Indian J Dermatol Venereol Leprol, 2006, 72, 119-125.

[12.] Tercedor J, Lopez-Hernandez B, Rodenas JM et al. Multivariate analysis of cutaneous markers of aging in chronic hemodialyzed patients. Int J Dermatol, 1995, 34, 546-550.

[13.] Choi HK, Thome FS, Orlandini T et al. Increased skin pigmentation in patients with chronic renal failure undergoing hemodialysis infected with the hepatitis C virus. Rev Assoc Med Bras, 2003, 49, 24-28.

M Rahmati Roodsari and F Malekzad

Department of Dermatology and Skin Research Center, Loghman-e-Hakim Hospital, Shaheed Beheshti University of Medical

Sciences, Tehran, Iran

Correspondence to: Mohammad Rahmati Roodsari, Department of Dermatology and Skin Research Center, Loghman-e-Hakim Hospital, Shaheed Beheshti University of Medical Sciences, Kamali Street, South Karegar Avenue, Tehran, Iran. (email: nimasarrafirad@yahoo.com)
Table 1: Frequency of skin diseases in haemodialysis
patients.

Disease Frequency (n) Percentage(%)

Yellow discoloration 93 43.3
Hyperpigmentation 77 35.8
Pallor 65 30.2
Ecchymosis 23 10.7
Solar elastosis 17 7.9
Pruritus Generalised 62 28.8
Localised 42 19.5
Xerosis 127 59.1
Prurigo nodularis 4 1.9
Lichen simplex 2 0.9
 chronicus
Excoriation 5 2.3
Absence of lunulae 30 14.0
Splinter haemorrhage 41 19.1
Leukonychia 2 0.9
Longitudinal ridging 55 25.6
Half-and-half nail 26 12.1
Koilonychia 22 10.2
Onycholysis 1 0.5
Contact dermatitis 1 0.5
Folliculitis 11 5.1
Furunculosis 2 0.9
Delayed wound healing 3 1.4

Table 2: The relationship between skin disease and occupation.
(ND; not detected).

 Housekeeper Indoor
 (n) employee (n)

Yellow discoloration Present 47 11
 ND 42 13

Hyperpigmentation Present 32 8
 ND 57 16

Pallor Present 34 6
 ND 55 18

Ecchymosis Present 16 2
 ND 73 22

Solar elastosis Present 5 0
 ND 84 24

Pruritus Generalised 25 5
 Localised 15 6
 ND 49 13

Xerosis Present 57 14
 ND 32 10

Prurigo nodularis Present 0 2
 ND 89 22

Lichen simplex Present 0 1
 ND 89 23

Excoriation Present 2 1
 ND 87 23

Absence of lunulae Present 13 4
 ND 76 20

Splinter haemorrhage Present 21 6
 ND 68 18

Leukonychia Present 2 0
 ND 87 24

Longitudinal ridging Present 20 7
 ND 69 17

Half-and-half nail Present 7 4
 ND 82 20

Koilonychia Present 9 4
 ND 80 20

Onycholysis Present 0 0
 ND 89 24

Contact dermatitis Present 0 1
 ND 89 23

Folliculitis Present 2 2
 ND 87 22

Furunculosis Present 1 0
 ND 88 24

Delayed wound Present 1 1
healing ND 88 23

 Outdoor Retired or
 employee (n) unemployed (n)

Yellow discoloration Present 10 21
 ND 8 45

Hyperpigmentation Present 8 24
 ND 10 42

Pallor Present 4 18
 ND 14 48

Ecchymosis Present 1 3
 ND 17 63

Solar elastosis Present 2 10
 ND 16 56

Pruritus Generalised 3 26
 Localised 3 12
 ND 12 28

Xerosis Present 11 36
 ND 7 30

Prurigo nodularis Present 0 1
 ND 18 65

Lichen simplex Present 0 1
 ND 18 65

Excoriation Present 0 2
 ND 18 64

Absence of lunulae Present 4 6
 ND 14 60

Splinter haemorrhage Present 1 11
 ND 17 55

Leukonychia Present 0 0
 ND 18 66

Longitudinal ridging Present 4 21
 ND 14 45

Half-and-half nail Present 4 10
 ND 14 56

Koilonychia Present 1 6
 ND 17 60

Onycholysis Present 1 0
 ND 17 66

Contact dermatitis Present 0 0
 ND 18 66

Folliculitis Present 0 2
 ND 18 64

Furunculosis Present 0 1
 ND 18 65

Delayed wound Present 0 1
healing ND 18 65

 Others
 (n)

Yellow discoloration Present 4
 ND 14

Hyperpigmentation Present 5
 ND 13

Pallor Present 3
 ND 15

Ecchymosis Present 1
 ND 17

Solar elastosis Present 0
 ND 18

Pruritus Generalised 3
 Localised 6
 ND 9

Xerosis Present 9
 ND 9

Prurigo nodularis Present 1
 ND 17

Lichen simplex Present 0
 ND 18

Excoriation Present 0
 ND 18

Absence of lunulae Present 3
 ND 15

Splinter haemorrhage Present 2
 ND 16

Leukonychia Present 0
 ND 18

Longitudinal ridging Present 3
 ND 15

Half-and-half nail Present 1
 ND 17

Koilonychia Present 2
 ND 16

Onycholysis Present 0
 ND 18

Contact dermatitis Present 0
 ND 18

Folliculitis Present 5
 ND 13

Furunculosis Present 0
 ND 18

Delayed wound Present 0
healing ND 18

Table 3: The relationship between underlying disease leading to CRF
and skin disease.

 DM HTN
 (n) (n)

Yellow discoloration Present 12 28
 ND 26 34

Hyperpigmentation Present 12 20
 ND 26 42

Pallor Present 15 11
 ND 23 51

Ecchymosis Present 7 6
 ND 31 56

Solar elastosis Present 4 6
 ND 34 56

Pruritus Generalised 14 17
 Localised 5 14
 No pruritus 19 31

Xerosis Present 23 39
 ND 15 23

Prurigo nodularis Present 0 1
 ND 38 61

Lichen simplex Present 0 1
 ND 38 61

Excoriation Present 0 2
 ND 38 60

Absence of lunulae Present 5 9
 ND 33 53

Splinter haemorrhage Present 9 12
 ND 29 50

Leukonychia Present 0 0
 ND 38 62

Longitudinal ridging Present 10 18
 ND 28 44

Half-and-half nail Present 5 8
 ND 33 54

Koilonychia Present 1 12
 ND 37 50

Onycholysis Present 0 0
 ND 38 62

Contact dermatitis Present 0 0
 ND 38 62

Folliculitis Present 2 4
 ND 36 58

Furunculosis Present 1 0
 ND 37 62

Delayed wound healing Present 0 0
 ND 38 62

 GN Cystic
 (n) kidney (n)

Yellow discoloration Present 4 10
 ND 8 4

Hyperpigmentation Present 4 7
 ND 8 7

Pallor Present 6 4
 ND 6 10

Ecchymosis Present 2 2
 ND 10 12

Solar elastosis Present 0 0
 ND 12 14

Pruritus Generalised 1 4
 Localised 3 6
 No pruritus 8 4

Xerosis Present 6 9
 ND 6 5

Prurigo nodularis Present 0 1
 ND 12 13

Lichen simplex Present 0 0
 ND 12 14

Excoriation Present 0 0
 ND 12 14

Absence of lunulae Present 2 1
 ND 10 13

Splinter haemorrhage Present 1 3
 ND 11 11

Leukonychia Present 0 0
 ND 12 14

Longitudinal ridging Present 0 4
 ND 12 10

Half-and-half nail Present 1 0
 ND 11 14

Koilonychia Present 1 0
 ND 11 14

Onycholysis Present 0 0
 ND 12 14

Contact dermatitis Present 0 1
 ND 12 13

Folliculitis Present 1 2
 ND 11 12

Furunculosis Present 0 0
 ND 12 14

Delayed wound healing Present 1 1
 ND 11 13

 DM and Others
 HTN (n) (n)

Yellow discoloration Present 6 33
 ND 4 46

Hyperpigmentation Present 4 30
 ND 6 49

Pallor Present 2 27
 ND 8 52

Ecchymosis Present 1 5
 ND 9 74

Solar elastosis Present 1 6
 ND 9 73

Pruritus Generalised 4 22
 Localised 1 13
 No pruritus 5 44

Xerosis Present 6 44
 ND 4 35

Prurigo nodularis Present 1 1
 ND 9 78

Lichen simplex Present 0 1
 ND 10 78

Excoriation Present 1 2
 ND 9 77

Absence of lunulae Present 1 12
 ND 9 67

Splinter haemorrhage Present 1 15
 ND 9 64

Leukonychia Present 0 2
 ND 10 77

Longitudinal ridging Present 5 18
 ND 5 61

Half-and-half nail Present 2 10
 ND 8 69

Koilonychia Present 1 7
 ND 9 72

Onycholysis Present 0 1
 ND 10 78

Contact dermatitis Present 0 0
 ND 10 79

Folliculitis Present 2 0
 ND 8 79

Furunculosis Present 1 0
 ND 9 79

Delayed wound healing Present 1 0
 ND 9 79

ND, not detected; DM, diabetes mellitus; HTN, hypertension;
GN, glomerulonephritis.
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Title Annotation:Case Report
Author:Roodsari, M. Rahmati; Malekzad, F.
Publication:Clinical Dermatology
Article Type:Clinical report
Date:Sep 1, 2007
Words:2884
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